Proctotomy leak following laparoscopic total gastrectomy with transrectal specimen extraction for gastric cancer: a case report

Abstract

Background Despite increasing acceptance in colorectal surgery, natural orifice specimen extraction (NOSE) surgery for the treatment of gastric cancer is still in its infancy, especially via the transrectal approach, which was barely reported. So little is known about its complications. Here we report the first case of proctotomy leak after transrectal NOSE gastrectomy, and our experience in preventive interventions. Case presentation A 62-year-old male patient complaining of upper abdominal pain who underwent open distal gastrectomy for gastric cancer one year ago was diagnosed with recurrent gastric cancer by gastroscopic biopsy. We performed laparoscopic total gastrectomy with transrectal specimen extraction on the patient. The operation was completed in a total laparoscopic approach and the specimen was extracted through a 3 cm longitudinal incision in the anterior wall of the upper rectum, then interrupted sutures were used for full-thickness closure of the rectal incision. The operative time was 470 min and intra-operative blood loss was 100 mL. The postoperative pathological examination showed pT1bN0M0 gastric adenocarcinoma. The patient developed proctotomy leak on the 10th postoperative day. We analyzed the causes of this rare complication and put forward a series of technical improvements. After failure of conservative treatment, a diverting ileostomy was created and the patient eventually recovered. We successfully prevented proctotomy leak in the subsequent 20 transrectal NOSE gastrectomies using improved techniques. Conclusions Proctotomy leak after transrectal specimen extraction should be considered among the complications of NOSE surgery and can be prevented by technical precautions.

Development and future perspectives of natural orifice specimen extraction surgery for gastric cancer

“…However, there was no significant difference in long-term survival between the two groups. This operation may lead to the leakage of digestive fluid, abdominal infection, as well as local, rectal, and vaginal incision recurrence[ 17 - 20 ].…”

Short-term outcomes of transvaginal specimen extraction versus transumbilical specimen extraction following totally laparoscopic gastrectomy in female patients with gastric cancer: a retrospective analysis.

“…Due to the questions about the necessity to avoid abdominal incisions and the psychological concerns of most surgeons, the NOSES gastrectomy was rarely reported from then on. Meanwhile, the NOSES procedure’s rectal incision increased the risk of intestinal fistula [ 15 ]. Therefore, the safety and feasibility of NOSES in gastrectomy still remain controversial.…”